The next topic for discussion in the naemsp dialog will be Prehospital
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| The next topic for discussion in the NAEMSP Dialog will be Prehospital
Pain Management. Confirmed invited participants include Michel Galinski, MD from the SAMU / SMUR ambulance service in Paris, France. He was the lead author of a study published in the July/Sept. 2010 issue of PEC entitled, "Prevalence and Management of Acute Pain in Prehospital Emergency Medicine." Keith Wesley, MD is the State EMS Medical Director for Minnesota and was an author of the NAEMSP Position Paper on Pain Management. Bryan Bledsoe, DO is a Clinical Professor of Emergency Medicine at the University of Nevada School of Medicine and the author of numerous EMS textbooks and journal articles.
colleagues who may be interested to join us. They may become a part of the Dialog group by visiting http://groups.google.com/group/naemsp-dialog and clicking the link to join this group. Thanks, --- Mic Mic Gunderson Editor / Moderator, NAEMSP Dialog; President, IPS The management of pain is an important topic that, in many EMS systems, does not get enough attention. This session of the NAEMSP Dialog will explore the issue and challenges of pain management in the field. This session begins today. Invited participants for this session will include: Paul Middleton, Paul Simpson and Jason Bendall - They are authors of the paper entitled “Effectiveness of Morphine, Fentanyl, and Methoxyflurane in the Prehospital Setting” that was published in the October-December issue of PEC. They are all affiliated with the Ambulance Research Institute at the Ambulance Service of New South Wales in Rozelle, NSW Australia.
“Prevalence and Management of Acute Pain in Prehospital Emergency Medicine” in the July September 2010 issue of PEC. He is with Hopital Avicenne, SAMU in Bobigny, France. Keith Wesley, MD is an author of the 2003 NAEMSP Position Paper entitled “Prehospital Pain Management”. He is the State EMS Medical Director for Minnesota and Medical Director for the HealthEast Medical Transportation in St. Paul, MN. Bryan Bledsoe, DO is a prolific author of EMS textbooks and journal articles – many of which have addressed prehospital pain management issues. He is a Clinical Professor of Emergency Medicine at the University of Nevada School of Medicine and an attending emergency physician at University Medical Center of Southern Nevada in Las Vegas.
Analgesia for the Prehospital Emergency Medical Services Patient” in the text on Emergency Sedation and Pain Management. He serves as Medical Director for the Colonie EMS and other agencies in the Capital District of New York. He is also the Director of Prehospital Care and Education and an Assistant Professor of Emergency Medicine at the Albany Medical College. This session will begin, per our usual process, with some initial discussion with the invited participants. The Dialog will be opened up for discussion among all Dialog members shortly thereafter. Please invite any colleagues who may be interested in this topic to join in by enrolling at http://groups.google.com/group/naemsp-dialog.
Mic Gunderson Editor / Moderator NAEMSP Dialog; President, IPS To get things started at a high level with our invited participants, I'd like to try and frame the areas we might want to address during the course of this discussion. What are some of the open questions that need to be answered through research or policy development related to prehospital pain management? What controversies are out there that need to be explored? What else should we address during this conversation over the next few weeks? I'll first ask this of the invited participants and will then open it up to all shortly. --- Mic Mic Gunderson Editor / Moderator NAEMSP Dialog; President, IPS I see the issue breaking down into the following areas 1. Appreciation for the role of pain management 2. Assessing pain scores 3. Determining the most appropriate for the condition 4. Determining what the goal is for pain relief 5. Addressing the special needs of pediatrics
1. Pain management alters the physical exam 2. Pain management removes a patient's ability to provide informed consent for additional treatment 3. Is there a role for holistic measures such as bio-feedback, acupressure, aroma therapy, etc. Keith Wesley, MD All,
Can we hold EMS to a higher standard than we expect of the rest of medicine? Of course we can! EMS is a unique environment where there is generally a provider or team of providers and a single patient; what needs to be present are reasonable protocols and opportunity for medication administration. Keith's topics are a great place to start. What are the best agents for us to use? Is there a place for non-steroidal medications in EMS, or should the basic agents used be inhaled, like nitrous oxide, or opiates, such as fentanyl. Pain scores are a great topic. To quote The House of God "You have to check a temperature to find a fever". You don't find pain unless you look for it. How are we looking for the fifth vital sign and are these techniques validated? In fact, do we need pain scores at all, or do we need to encourage verbal assessment and recording? After all, has anyone ever heard "Boy does it hurt--it's an 11 out of 10!" The authors of some great studies and papers are going to be on this thread. Another great question: Does anyone have any new techniques to teach pain management to new and currently practicing providers? Michael Michael W. Dailey, MD FACEP This gets us off to a good start - thank you Keith and Mike. Our other invited participants (Bryan, Paul M, Paul S, Jason and Michel) are still welcome to chime in with their thoughts.
do each of you think are the open questions that need to be answered through research or policy development related to prehospital pain management? What are the controversies are out there that need to be explored? What else should we address during this conversation over the next few weeks? A gentle reminder to all - our decorum is that all posts should include your name and affiliation. This is a moderated forum, so if a post is submitted without this information, you may be asked to resubmit with it included (http://groups.google.com/group/naemsp- dialog/web/guidelines-of-decorum).
Mic Gunderson Editor / Moderator, NAEMSP Dialog; President, IPS Looking forward to this important topic. Dr Koehler Alaska I think the topic of prehospital pain management is a very important one. This is a weapon in the paramedic arsenal that is often overlooked when indicated. I have written about this specific topic a few times on my blog and as an advocate for more liberal use of pain management, I will provide some research abstracts to get the ball rolling. I am especially excited to see the prestigious panel for this topic. From Pubmed: [1]
Am J Emerg Med. 2010 Mar 25. [Epub ahead of print] Predictors of pain relief and adverse events in patients receiving opioids in a prehospital setting. Bounes V, Barniol C, Minville V, Houze-Cerfon CH, Ducassé JL. SAMU 31, Pôle de médecine d'urgences, Hôpitaux Universitaires, 31059 Toulouse cedex 9, France. Abstract OBJECTIVE: The aim of the study was to analyze factors predicting pain relief and adverse events in patients receiving opioids for acute pain in a prehospital setting. METHODS: In this prospective, observational clinical study, adult patients with a numerical rating scale (NRS) score of 5 of 10 or higher who required treatment with intravenous opioids for pain control were included. The primary outcome variable was final analgesia defined by an NRS score of 3 of 10 or lower upon arrival to the emergency department. Univariable and multivariable analyses were performed to identify predictive factors of pain relief and adverse effects. RESULTS: In total, 277 patients (age, 49 ± 22 years), 205 (74%) of whom were male and 154 (56%) with a traumatic pain were included in the analysis. Median (interquartile range) NRS scores at baseline and at discharge were 8 of 10 (7-10) and 3 of 10 (2-5), respectively. The final model had 3 independent variables reaching significance. Physician-staffed ambulance transportation (odds ratio [OR], 2.42; 95% confidence interval [CI], 1.07-5.49) was the only independent predictor of patients' final pain relief. High initial pain scores and acetaminophen use were predictive factors for failure of analgesia (OR, 0.79; 95% CI, 0.68-0.93 for one unit/10; P < .01; and OR, 0.40; 95% CI, 0.21-0.77; P < .01, respectively). In the entire sample, 25 (9.0%) presented one adverse effect, all mild to moderate in severity, with no significant predictive factors. CONCLUSION: Despite advancement in prehospital pain management, pain relief at discharge is still inadequate in some patients. Finally, one important message of our study is that patients in pain have to be transported by well-equipped and staffed ambulances to reevaluate and alleviate pain. [2] J Eval Clin Pract. 2010 Aug 13. [Epub ahead of print] Exploratory cross-sectional study of factors associated with pre- hospital management of pain. Siriwardena AN, Shaw D, Bouliotis G. Professor of Primary and Prehospital Health Care, Faculty of Health, Life and Social Sciences, University of Lincoln, Lincoln, UK and Associate Clinical Director, East Midlands Ambulance Service NHS Trust, Lincolnshire Divisional Headquarters, Cross O'Cliff Court, Bracebridge Heath, Lincoln, UK. Abstract Abstract Rationale, aims and objectives Improving pain management is important in pre-hospital settings. We aimed to investigate how pain was managed in pre-hospital suspected acute myocardial infarction (AMI) or fracture and how this could be improved. Method We conducted a cross-sectional study in Lincolnshire using recorded suspected AMI and fracture between April 2005 and March 2006. Outcomes included pain assessment, improvement in pain scores and administration of Entonox, opiates or GTN (in AMI). Results We accessed 3654 patients with suspected AMI or fracture. Pain was assessed in over three quarters of patients but analgesics administered in under two-fifths. Assessment was more likely in patients with suspected AMI (OR 2.05, 95% CI [1.70, 2.47]), and who were alert (OR 3.55, 95% CI [2.32, 5.43]). Entonox was less likely to be administered for suspected AMI (OR 0.11, 95% CI [0.087, 0.15]) or by paramedic crews (OR 0.56, 95% CI [0.45, 0.68]) but more likely to be given when pain had been assessed (OR 3.54, 95% CI [2.77, 4.52]). Opiates were more likely to be prescribed for suspected AMI (OR 1.30, 95% CI [1.07, 1.57]), in alert patients (OR 1.35, 95% CI [0.71, 2.56]) assessed for pain (OR 2.20, 95% CI [1.73, 2.80]) by paramedic crews. Conclusions This exploratory study showed shortfalls in assessment and treatment of pain, but also demonstrated that assessment of pain was associated with more effective treatment. Further research is needed to understand barriers to pre-hospital pain management and investigate mechanisms to overcome these. These are just two of the most recent studies. Adam Thompson, EMT - P Paramedicine101.com I am looking forward to this discussion. Pre hospital pain management is one of the ways we really can make a difference. Margaret A. Keavney I would like to see some discussion about drug seeking and the degree to which perceptions about drug seeking hinder appropriate pain management in the field. Also, reasons why so many jurisdictions require paramedics to call in for orders for analgesics when so many (arguably far more dangerous) drugs can be given by standing order. Finally, some discussion about entering patients into a pain management protocol as opposed to dictating a specific dose that may or may not be therapeutic for the patient. Thanks, Tom
-- Tom Bouthillet Lieutenant / Paramedic Town of Hilton Head Island Fire & Rescue Division 843-247-3453 (cell) ems12lead.com @tbouthillet / @EMS12Lead Hello to all,
Paramedic Research Fellow/Intensive Care Paramedic, Ambulance Research Institute Ambulance Service of New South Wales, Australia Paul,
to have a perspective from the EMS community in Australia. For everyone's reference, the paper that Paul Simpson was a contributing author on (with Paul Middleton and Jason Bendall and others) is now posted in the files section of the NAEMSP Dialog site. It is there along with the paper by Michel Galinski et al and the NAEMSP Position Paper on pain management that Keith Wesley was a co- author on. I'll put some links to these papers on the pain management resource page as well in the coming days.
"Topic004-" as they will be the ones associated with the pain management topic.
Mic Gunderson Editor / Moderator, NAEMSP Dialog; President, IPS Hi All, I too am looking forward to this discussion. Over here in the UK we seem to have some positives to our management of pre-hospital pain. We have a number of options available to us including entonox, paracetamol, ibuprofen, oral morphine and Morphine IV. By far though, the best thing that we have is the ability to make the decision on what analgesia and how much to give the patient. For severe pain, when I am giving Morphine, my dose is simply titrated to effect. My normal standard max dose is 20mg IV but there have been times when I have exceeded that dose, as long as I have been able to rationalise why and show on the clinical report that the patient was not suffering any of the troubling side effects at that time. Basically if the patient is in significant pain, BP, pulses, GCS, resps and SaO2 are all stable and within normal limits , then they will be given Morphine titrated to effect. From what I have witnessed from my travels to the States and reading many US EMS blogs, there seems to be much tighter reigns on the administration of opioids in the pre-hospital environment. I am a staunch advocate for actively treating pain in the prehospital arena. Even on short journeys to hospital, if the patient is scoring their pain above 5 on a 0-10 scale, I will intervene with an appropriate analgesic. It takes time for the patient to be triaged and seen by a Doctor, so why make the patient suffer for longer than is absolutely necessary? Unless you are still one of those providers that believes analgesia should be with-held so that the A&E/ER doc can see where the patients pain is and how severe it is? Mark Glencorse, Paramedic Team Leader, North East Ambulance Service NHS Trust, UK Author of www.999medic.com Applicability of pain scales is problematic. In our practice, we are arbitrarily held to The Joint Commission (TJC) standards on pain assessment. However, this is really the only national standard which is currently enforced in hospital. In my protocols, I have given guidance to my prehospital providers to assess and treat pain aggressively with scores of 5 or greater being treated with the option of NSAID (Ketorolac) or OPOID (Fentanyl) depending on the mechanism of injury (MS vs Trauma). Also is given the leeway to hold analgesic due to other influencing factors (chronic opiod patient whom appears sedated already, conflicting medications/interactions, vital sign/mental status abnormalities) as long as they can paint that picture to me in their prehospital report as to the reasoning process on why they have withheld medication.
Chief, Department of Emergency Medicine Chief, Fort Campbell Emergency Medical Services Medical Director, Fort Campbell Fire and Emergency Services First off....Thank you Mic for launching this dialogue. Most of the folks who call 911 hurt, are having difficulty breathing, have had something bad happen to them, feel real sick, or are with someone who they can't wake up. I'm a firm believer in addressing a patients "inspiration for calling 911" as part of any treatment protocol. Since pain is involved in many if not most of the presenting problems we deal with I believe that pain management is an essential part of our practice. There are a few issues related to this topic that I would love to have our expert group chat about in addition to those already mentioned.
Mike Taigman Old Medic General Manager AMR AlCo Mike, I too have seen many, many providers making the judgement on the patients pain for them. Yes, there are some times that the patient is very clearly and obviously in pain and if it is a result of an obvious traumatic injury, then it is a very easy step to move towards the higher levels of the 'analgesic ladder' sooner rather than later. Where the real difficulty comes in is with the patients who call for a pain related illness e.g. the chronic undiagnosable abdominal pain. Again, if someone is clearly distressed then its an easy decision to make, but what about those who are outwardly coping with their pain ; who show no physiological alterations in BP or pulse, who look comfortable and at relative ease, but who score their pain at 10 out of 10? I still remember the quote from McCaffery & Beebe (1989) that was drilled into me whilst completing my nurse training in the early 90`s. "pain is whatever the person experiencing it says it is, and exists where [the person] says it does" I still go with this opinion and try to always believe what the patient tells me. That doesn't mean that the patient is going to get Morphine from me though, they may get something lower down the ladder and see how that works for them (if the travel time allows for that). My Mantra has always been, and will always be "If in doubt I will always go with the patients pain score, I would never want to withhold analgesia from a patient who needs it just because I suspect that they maywant it instead.
through the administration of an opioid, that is something that is currently being investigated with a research project within my trust.
however my service has chosen not implement this as the have found that the evidence points to nausea and vomiting being vastly minimised through the appropriate slow administration of Morphine along with a titration to effect rather than a bolus dose. I have found this to be true, but I would still like and anti-emetic to be able to give patients who are nauseous or vomiting already
Mark Glencorse, Paramedic Team Leader, North East Ambulance Service NHS Trust Blog: www.999medic.com Twitter : @UKMedic999 Skype: markglencorse Mobile: 07850 042620 (Posted on behalf of Michel Galinski, MD, SAMU, France)
management. Currently there are lot of studies done all along the last 20 years about acute abdominal pain. Should we treat pain before the surgeon see the patient. Most of studies said Yes. The pain management with morphine of an abdominal pain, in children or in adults, does not change the diagnostic. (Pace S.Acad Emerg Med 1996;3:1086-92; Attard AR. BMJ 1992;305:554-6). In ours days diagnosis are helped by UltraSonography or tomodensitometry scan. The clinician good sense could say that it is easier to question and to make an examination of a patient about his pain when he has no pain any more (after treatment).Imagine a patient who is crying or moving because of his acute pain. So we could say that pain management improves the physical exam.
pain. The patient called because of it. We know that. But arguments about an acute coronary syndrome come fron the patient history, cardiovascular risk factors , characteritics of pain (which could be obtain even pain is disappeared) and EKG; Maybe the real questions could be: is there a risk to not treat a severe pain? Is it necessary to treat pain in the prehospital setting? If yes how to do that? What are the limitations? Well that did not work... let's try again. Pardon the technical glitch. --- Mic (Re-posted on behalf of Art Samaras, Morristown, NJ [to keep the entire pain discussion in the same thread]) Dr Wesley provided several controversies for this discussion on his post, the first being that pain management potentially altering the physical exam.
issue. What ailments present where this is specifically an issue? For example, in severe burn patients, pain does not often assist the receiving team with being able to assess the patient. Some of our neurosurgeons, on the other hand, often ask that we withhold prehospital pain management from a patient with a suspected neuro impairment until they have had the opportunity to assess the patient. Looking forward to the conversation. Thanks, Art Samaras, NREMTP, FPC Atlantic Ambulance Morristown, NJ Hi
CNRD
Centre National de Ressources de lutte contre la Douleur Hôpital Armand Trousseau 26, av Arnold Netter 75571 Paris Cédex 12 Tel : +33 144735426 Secrétariat: +33 144735421 Hi All,
South Africa. I do no prehospital work now, but spent 34 years as a volunteer in mountain rescue, some of that time representing the Mountain Club of South Africa on the international Commission for Alpine Rescue ( Medical Commission).
treated, but it is only part of the unpleasant experience that the patient will have during the initial part of an injury or illness. At least the main treating doctor ( or Paramedic where applicable ) should introduce himself and make physical contact such as holding the patient's hand, or feeling the pulse frequently, listening to the breathing with a stethescope or however else one can touch. As soon as possible the situation and what is going to happen should be explained to the patient in simple language, and re-explained as frequently as needed because injury, pain, and drugs will prevent the patient from remembering what you told him. I know as well as you do that many places are too noisy to hear anything, but the contact is the important thing here - the patient thinks that somebody cares about him as a person rather than an item to be removed from one place to another. It is almost always possible to communicate with the patient and try to understand what he is replying. If the patient knows you, even in a very little way, he will trust you much more, and so feel better about himself within the situation and fear will be decreased. He also needs to be kept warm ( or cool in a hot climate ), thirst can be decreased by intravenous fluids or drinking as suitable, noise must be decreased as much as possible, as should vibration and other movements that can cause motion sickness, he needs enough oxygen to prevent dyspnoea at altitude, an empty bladder and where possible a full stomach. Nausea can be minimised, and I favour cyclizine because it prevents both drug induced nausea and motion sickness.
possible but remember to move him enough to prevent "pressure sores", padding and immobilisation of injured parts, Transcutaneous Electrical Nerve Stimulation (= TENS, a stupid man's accupuncture that is easy to use and may have good analgesic effects but discuss this with the helicopter's pilot first ). Standard analgesics have been mentioned before, but a few others that can be thought about are ketamine ( Ketalar ) which is an excellent analgesic in it self, but also is a NMDA nerve receptor antagonist and prevents "wind-up" which will increase any pain that remains for a long time. This drug can be given by any route, in doses of the order of 0,1mg / kg body mass IV, 1-2mg/kg body mass IM or Sub Cutaneous, 0,5 - 1 mg/kg body mass by mouth ( well dilute since it tastes awful ). Since safe anaesthetic doses are about ten times these doses, you do not need to worry too much about the dangers of the drug. It works very rapidly but for a short time after IV , and takes about 30 - 45 minutes after oral dosing. It can be given in these doses with full doses of other analgesics. For those who have in hospital experience, nerve blocks with local anaesthetics can be used, but with due respect for their dangers. In hungry neonates plain sucrose ( cane sugar ) given by mouth seems to decrease pain and suffering. Anxiolytics and sedatives can help but they will increase the dangers of analgesics and may make care of the patient in an unstable environment more difficult.
Hi
About the treatment of pain: We have two principles 1 - the treatment has to be adapted to pain intensity, patient and pathology 2 - the different pain killer should be associated (multimodal analgesia)
2 to 3mg/kg IV are anesthesiologic doses. Michel Galinski CNRD
Centre National de Ressources de lutte contre la Douleur Hôpital Armand Trousseau 26, av Arnold Netter 75571 Paris Cédex 12 Tel : +33 144735426 Secrétariat: +33 144735421 One aspect that has not been discussed is restrictive state mandated protocols that limit a medical director's ability to choose appropriate analgesics for those paramedics working under her/his license. For example, Arizona, USA, where I live, has very archaic and restrictive protocols which must be adhered to by all EMS services. Morphine is the only opioid allowed. Paramedics are not allowed to give fentanyl. Only nurses can give fentanyl in the field, which at least allows flight nurses to use it. AZ also has a system of base hospitals that mandates that every EMS service be tied to a base hospital. The base hospitals have what are called "prehospital coordinators" which are always nurses, most of which have never spent more than an hour or two in an ambulance. One of them said to me that "fentanyl has no place in EMS. Our ER doctors cannot even use it." When one lives in a place like Arizona, it's useless to discuss choices in prehospital analgesia because there are none. And it's useless to discuss titration, because the state protocols do not mention it. They call for set doses, regardless of patient weight or other factors that might enter the minds of somebody who knew what s/he was doing. As an EMS educator, I go beyond state protocols and teach my students the theories of pain management, but they will never be able to use them if they practice in Arizona. I would be interested to know whether or not other states have such restrictive rules. Gene Gandy, JD, LP, NREMT-P EMS Educator Tucson, AZ Gene,
I was convinced from my practice in EMS and in the ED that fentanyl was the best choice of prehospital opiate before I added the use of the mucosal atomizer to my skill set, and now I am even more convinced. Fentanyl intranasal is hands down the best way to management acute traumatic pain in children, and for adults, the rapid onset, short half-life, minimal histamine release and hemodynamic profile make it the all-round best agent. Dr. Galinski's study comparing F and M was small and had a non-significant trend toward better relief with F. More than anything else it, and work by others including Gallagher in the ED, have demonstrated that the best way to get relief of pain for our patients is to give those administering analgesia the latitude to give more if needed. As Dr. Galinski says, the treatment must "be adapted to pain intensity, patient and pathology." Our providers have the skill to manage pain; we need to give them the tools they need to do it. MD Michael W. Dailey, MD FACEP Director of Prehospital Care and Education Associate Professor of Emergency Medicine Albany Medical Center 518/ 262-3773 One issue that I have not been able to resolve is that in tiered EMS systems, patients that may need analgesia are triaged to BLS units. For example, the fall with arm/hip fracture or headache may be triaged to BLS providers. How do we reconcile this? Derek Isenberg, MD, NREMT-P Medical Director Mercy EMS Mercy Catholic Medical Center Department of Emergency Medicine 501 South 54th Street Philadelphia, PA 19143 215.748.9740 215.748.9208 (fax) Gene,
Director for Colorado, it is hard for me to understand how statewide mandates get passed that are so restrictive that they negatively affect patient care. How can a prehospital provider possibly provide adequate care with only one opioid choice? What do they do when a patient requires pain management and the patient is allergic to morphine? Pain is too prevalent of a complaint in EMS to not give paramedics appropriate tools to manage. A single opioid is simply inadequate and not providing early pain management is simply poor patient care. Fentanyl is such a safe and effective medication available for field use that I almost cannot believe that any EMS agency would function without it in their toolbox. I had the good fortune of being involved with a very progressive private ambulance service (Pridemark Paramedics) from 1999 – 2005. During that time we were able to complete a fairly extensive study of prehospital pain management and the use of fentanyl and morphine. From the study data we published an article that dealt with the safety and efficacy of fentanyl in over 2100 patients (PREHOSPITAL EMERGENCY CARE 2006;10:1–7). We had plans to also publish some of that comparative data (morphine vs fentanyl) but unfortunately I left Pridemark prior to completing that part of the study. However, fentanyl is clearly a safe and very effective opioid available for prehospital use. Please feel free to share the article published in Prehosital Emergency Care with the appropriate powers in Arizona. If I can be of any help I would be happy to personally share my perspective as well as the data from our study and what we learned. I have included the abstract below. Arthur Kanowitz MD FACEP State Medical Director Emergency Medical and Trauma Services Section Health Facilities and Emergency Medical Services Division Colorado Department of Public Health and Environment 4300 Cherry Creek Drive South Denver. Colorado 80246-1530 office 303 692-2984 mobile 720 641-3540
PAIN MANAGEMENT Arthur Kanowitz, MD, Thomas M. Dunn, PhD, NREMT-B, Elyse M. Kanowitz, 5 BA, WilliamW. Dunn, BA, NREMT-P, Kayleen VanBuskirk, BA ABSTRACT Objective. To determine the safety and effectiveness of fentanyl administration for prehospital pain management. Methods. This was a retrospective chart review of patients transported by ambulance during 2002–2003 who were administered fentanyl citrate in an out-of-hospital setting. Pre and post-pain-management data were abstracted, including vital signs, verbal numeric pain scale scores, medications administered, and recovery interventions. In addition, the emergency department (ED) charts of a subgroup of these patients were reviewed for similar data elements. Results. Of 2,129 patients who received fentanyl for prehospital analgesia, only
12 (0.6%) had a vital sign abnormality that could have been caused by the administration of fentanyl. Only one (0.2%) of the 611 patients who had both field and ED charts reviewed had a vital sign abnormality that necessitated a recovery intervention. There were no admissions to the hospital, or patient deaths, attributed to fentanyl use. There was a statistically significant improvement in subjective pain scale scores (8.4 to 3.7). Clinically, this correlates with improvement from severe to mild pain. Conclusion. This study showed that fentanyl was effective in decreasing pain scores without causing significant hypotension, respiratory depression, hypoxemia, or sedation. Thus, fentanyl citrate can be used safely and effectively for pain management in the out-of-hospital arena. Michael, I'm glad to see that NY is progressing and that some progress is being made elsewhere. I'm afraid that it's going to take some retirements and funerals here in AZ before anything will change. Gene Gene Gandy, JD, LP, NREMT-P My view: If they need analgesia, then they should not be triaged to a BLS unit. Period. BTW, the dirty lawyers are beginning to wake up to the lack of pain management in prehospital care. Beware. Gene Gandy, JD, LP, NREMT-P In the case of AZ, I think it's because the same entrenched people have "run" EMS here for decades. I do know that the AZ State Medical Director, Dr. Bently Bobrow seems to be somewhat progressive and I hope the situation may change soon. Thanks for the article. Actually I was aware of it and have it in my archives.
Gene Gandy, JD, LP, NREMT-P Hi
1 - I would like to insiste in the fact that morphine has got the same efficiency than fentanyl or sufentanil (2 studies in prehospital setting about this subject Galinski Am J Emerg Med 2005; Bounes Ann Emerg Med 2010 ). 2 - Opioids (morphine) is not the only pain killer which can be use: paracetamol, NSAI drugs, nitrous oxid can be use togother or with morphine (multimodal analgesia). 3 - In our country (France) "paramedic teams" which are fire man, do not have analgesic at all. If a patient is very panfull they call an EMS which are staffed by an emergency physician and nurse who are going to do analgesia. 4 - In emergency room, nurses can give morphine following a strict analgesic protocol before the physician see the patient. But nurses received a specific formation about morphine. This point is fundamental.
without a titration of morphine. We can not know in advance which dose of morphine is going to be efficient for this patient. And this dose is going to be different from another patient with the same pathology. This necessitate a strong formation about morphine because this good and efficient drug has, as all opioids, side effects one of which is respiratory depression.
emergency physician and his team is indispendable. Some time we have to do sedation or general anesthesia in the field.
Centre National de Ressources de lutte contre la Douleur - CNRD. H�pital Armand Trousseau 26, av Arnold Netter 75571 Paris cedex 12 Secretariat: 01 44 73 54 21 Site internet: www.cnrd.fr
Hi
Of course fentanyl is efficient for pain relief . It is a powerful analgesic as sufentanil. The question was not there. The questions is : Is morphine less powerful than fentanyl or sufentanil ? A recent study compared sufentanil and morphine in prehospital setting (Bounes et al Ann Emerg Med 2010 [epub ahead of print] . This controlled, randomised and double blind trial (108 patiens included) showed 2 importants thing: in the first 15 minutes of titration (measurement of pain intensity each 3 min), sufentanil group obtained a better score than morphine group at time 9 min only. This is logical because the sufentanil onset of action is shorter than morphine one (2 minutes vs 5 min). At time 12 minutes, there was a steady state between the 2 groups, no difference at T12 and T 15 minutes. The followup of patients during 6 hours showed clearly that the morphine duration of action was superior than sufentanil one. During the first 6 h, 32% of morphine group was administered analgesic medication versus 51% in the sufentanil group. Conclusion: this study confirm the results about previous study fentanyl (same family of opioid that sufentanil) in prehospital setting; morphine has the same efficiency than sufentanil but its duration of action is longer (which it is not a surprise). The message is that the opioid nature it is not the problem. The problem is the possibility to use it when it is necessary and to use it in good conditions. The side effects of fentanyl, sufentanil or morphine are the same. Titration is the best way to find the best dose. Michel Galinski Centre National de Ressources de lutte contre la Douleur - CNRD. H�pital Armand Trousseau 26, av Arnold Netter 75571 Paris cedex 12 Secretariat: 01 44 73 54 21 Site internet: www.cnrd.fr
Dr. Isenberg's question is vital. Do you have policy for which patients go ALS vs. BLS? I do and need for perenteral pain management is ALS. Keith Wesley, MD Medical Director HealthEast Medical Transportation St. Paul, MN Keith,
policy development perspective, what SHOULD the options be for a BLS service? This brings to mind the various non-pharmacologic methods that you and others have mentioned in earlier posts. Should these non-pharmacologic methods get more attention even from ALS providers? I'm thinking about cold packs, positioning, transcutaneous electronic nerve stimulators (TENS), audio analgesia, guided imagery, etc.
nitrous oxide / 50% oxygen mixtures by BLS crews (assuming appropriate protocols and training).
Mic Gunderson Editor / Moderator, NAEMSP Dialog; President, IPS (Re-posted on behalf of Michael Daliey [to keep the entire discussion within the same thread]) Great question Art. Frankly, pain management should not alter a neurologic exam if titrated appropriately. Gentle and judicious, improvement of discomfort, rather than a goal of removal of all pain. Some other postings have commented on protocols for opiate administration rather than fixed doses, and giving the medication the patient requires for pain. With guidance from a weight based dosing, this may be the best way to go. May there be a case that the pain is needed for diagnosis? Perhaps. But if you use a short acting agent like fentanyl, in most cases the medication will be wearing off prior to the physician getting to the bedside. Michael W. Dailey, MD FACEP Director of Prehospital Care and Education Associate Professor of Emergency Medicine Albany Medical Center 518/ 262-3773
Hello!
Pennsylania Emergency Medical Services for twenty-three years with the last seventeen years as a Nationally Registered Paramedic. I am very interested in learning about the constant changes that are occuring in pre-hospital medicine. I am happy that pain management has become a priority in the pre-hospital management of a patient even though it was way overdue. However, I think the biggest issue that faces pre-hospital providers are the "drug-seekers" and the concern of an Emergency Room physician/nurse saying "oh this guy is a drug-seeker how did you fall for that?"
stereotypes and fear which results in hesitation on performing pain management. My question is how do we train our younger providers, physicians, and nurses to overcome this stereotype and at the same time recognize someone who is abusing the systems and is attempting to feed into an addiction? Erik Davis AS, NREMT-P Mercy Health Systems Philadelphia, Pennsylvania
Dr. Isenberg's concern about patient's needing pain management and being triaged to BLS is a valid concern.
both with the BLS and ALS providers. Currently, in our system the BLS provider is typically dispatched alone for fractures/pain type emergencies. After arriving on location, they perform the necessary Basic Life Support skills and then transport the patient. One way to correct this issue is to change their way of thinking via training. Let's teach the Emergency Medical Technicians on how to evaluate the severity of pain and determine the necessity of pain management. Simultaneously, we need to change the thinking of Paramedics. There is a belief with some Paramedics that "well, by the time they dispatch me and I get there they could be at the hospital." I think this type of mentality/behavior needs to change for pain management to be truly effective. Erik Davis AS, NREMT-P Mercy Health Systems Philadelphia, Pennsylvania
You're right, but it's also about changing the thinking ABOUT BLS and ALS providers. For example, it's hard to insist on all-volunteer EMT services [to cut costs], and at the same time add responsibilities and training requirements associated with medication administration. In addition, the CQI process for all those calls needs to be in place. If the person accomplishing the CQI process is donating his/her time, and the EMTs are volunteer, what kind of service do you expect? Don't get me wrong, I have the utmost respect for those volunteering their time to train and practice out-of-hospital medicine. We have momentum now, increasing the professionalism and standardization of training for EMS providers. We need to advocate for their remuneration. Carin M. Van Gelder, MD FACEP FAAEM EMS Medical Director, NHSHP Assistant Professor, Dept of Emergency Medicine Yale University School of Medicine ph (203) 785-6159 c (203) 627-7414 f (203) 785-3196
Is this still an issue--concerns that analgesics will blunt the exam? Most abdominal and surgical emergencies are diagnosed with CT or ultrasound. The patient's mentation plays a decreasing role. Bryan --
Bryan E. Bledsoe, DO, FACEP, FAAEM Clinical Professor of Emergency Medicine University of Nevada School of Medicine Attending Emergency Physician University Medical Center of Southern Nevada Medical Director, MedicWest Ambulance Las Vegas, Nevada
Erik has hit one of the crucial points. Simply put, drug seekers do not use 9-1-1. They don't want a shot, they want a prescription. I remember an article awhile back about Headache patients and EMS. Headache patients are a frequent source of drug seekers but this article showed that patients with a compliant of headache that came by EMS were almost always sick and had a real need for evaluation and care. Interestingly, the current edition of the Carolyn AAOS Paramedic text devoted 2 pages to identifying drug seekers. This is not appropriate. No more than blowing someone off with a complaint of chest pain because you just don't believe them.
Mic is absolutely correct in that pain control is not always a drug. As with many things in EMS, ALS has forgotten that basic skills provide the majority of care. I would never advocate for a single BLS service to institute an ALS intercept simply to treat pain. Dispatch is the best time to determine whether or not the condition is one that merits pain control and then send ALS.
Medical Director HealthEast Transportation St. Paul, MN Dear Dialog readers,
current practices which others may not be aware of. A previous contributor suggested drug seekers do NOT dial 9-1-1. I wish that was true for my EMS providers. In Alaska there are vast areas where no pharmacies exist and our volunteer EMS providers are quite fatigued and demoralized from drug abusers calling 9-1-1. Many drug seekers have been cut off from the few existing clinics with dispensaries and ER's, leaving 9-1-1 the only access to a quick fix when other avenues dry up. There are various manipulations and scenarios which these patients devise and I cannot expect a volunteer EMS person to judge whether or not to give Morphine and then transport to the nearest hospital which can be 100 miles away. When a citizen takes a day off from paid employment to respond to one of these calls, it sucks a their will to provide community service. TWO articles are worth review: 1. CDC MMWR report (59:32 1026) "The number of poisoning deaths from opiates (1997=4000 deaths 2007=14,500 deaths)" 2. CDC MMWR report (59 (30);957 Death Rates for the three leading causes of Injury Death" in which deaths from MVA and firearms has dropped but death from drugs is on exponential rise. My next email will separately discuss the use of multiple controlled substances in volunteer or rural EMS agencies. Danita Koehler, MD Chief, EMS US Army- Alaska
Several years ago I was on a prehospital pain management panel at the University of Western Australia. They were making significant progress in switching to ketamine for many painful conditions--especially trauma. Has anybody had much prehospital experience with using ketamine in the States?
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Bryan E. Bledsoe, DO, FACEP, FAAEM Clinical Professor of Emergency Medicine University of Nevada School of Medicine Attending Emergency Physician Medical Director, MedicWest Ambulance University Medical Center of Southern Nevada Las Vegas, Nevada
My Take: Pain management starts with stress reduction and visa versa. One common modality that is often overlooked is the use of an ice/cold pack. For musculosckeletal injuries, this is often my primary treatment. I believe that, in general, all [prehospital] healthcare providers, including myself are poor providers of pain management. As mentioned by the others here, this is all-to-often as a result of those whom inappropriately seek pain management. Also, not trusting the patient's representation of the severity of pain. Both should have no baring in the back of an ambulance. Maybe the paramedicine curriculum has changed, but I don't remember the part of the text book that mentions drug addiction as a contraindication to pain management. Dr Bledsoe?
they are most definitely worse than the symptoms that will present after a therapeutic level of pain relief is reached. The most common symptom there is PAIN RELIEF. Drug seeker = someone still in pain. Not that every one deemed a drug seeker really is, but lets consider the consequences of providing them with what they want. Many who fall victim to opiod/opiate addiction do so because of an initial symptom of pain. They found relief with the drugs, and found pain when they stopped taking them. So when they present to EMS with a complaint of pain, they probably have pain. Yes, it may be pain due to the falling levels of narcotic within their body, but do you know that? More importantly, do you care? They are in pain, and we can treat pain. This is an extreme argument I know. The argument against this could be a straw man built on the basis that this would lead to an EMS pain relief dependancy, or contribution to the problem. Until us paramedics are taught differently, shouldn't we do what we are taught? The complaint is real unless proven otherwise.
need to rethink the way we withhold pain management. And by 'rethink', I mean 'omit'.
If epinephrine was a schedule one narcotic that was commonly abused, would you withhold it if an "epi-abuser" presented with anaphylaxis? The drug abuser is often in more pain than the patient who has never had an opiate in their system. We aren't handing out prescriptions or giving large doses, we are just getting them to the hospital. This is just my point-of-view and I am aware of the holes. Nothing is absolute and this is no exception. Adam Thompson, EMT-P Lee County EMS EMS Educator - Edison State College Paramedicine101.com EMSresponder.com Lee County, Florida Dr. Wesley, Presuming that article was based on evidence, do you remember the title of the study? That would be an abstract worth reading. How do we fix the problem that is subpar pain management by utilizing evidence? Do we obtain tox-screens on all non-recipients of pain management, and use those results to quantify the prehospital provider's ability to judge who is or is not a drug seeker? I actually think that is an idea worth looking in to, but more-so I think taking your approach may lead to an improved level of care. Consider the patient complaining of pain to truly be in pain until proven otherwise. As for the sub-standard state guidelines for prehospital pain management go, that is very unfortunate. I would like to hear that there is a change in the works. I have also heard of restrictive protocols that only allow the paramedic to administer certain pain therapies after receiving online medical direction. I have heard many stories of systems like this, and the paramedics within them becoming discouraged after continually being refused when attempting to obtain valid orders. Is anyone aware of any research done on systems like these? Does anyone work in one of these systems?
Lee County EMS EMS Educator - Edison State College Paramedicine101.com EMSresponder.com Lee County, Florida Thirty years ago many services in Texas were using Nitronox (50% nitrous/50% oxygen) but the cost of the rig was high, and abuse among EMTs and others was high (I knew one boozing fire chief who would get his Nitronox fix first thing every morning). Eventually use tapered off. That's too bad, because I think it's an appropriate method for basic EMTs to use. The reason for the expense is that there must be a regulator that will shut the nitrous off if the oxygen runs out, and that's apparently somewhat more expensive than an oxygen regulator. My information may be old like me. I haven't looked into the currently available rigs. Gene Gene Gandy, JD, LP, NREMT-P Dr. Bledsoe, I rarely still have this issue, though it is still often preached as a current problem. If it is a problem, why don't the physicians that have this concern teach their paramedics how to perform and document a good physical exam? They would have their baseline findings and a patient with some pain relief.
the issues stated thus far within this discussion, what would you consider realistic solutions to these problems?
Lee County EMS EMS Educator - Edison State College Paramedicine101.com EMSresponder.com Lee County, Florida We should not get hung up too much on so called drug seekers. It is not the patient's job to prove they are in pain. Prehospital providers should treat pain as appropriate and not try to determine who is real and who is not. Derek Derek Isenberg, MD, NREMT-P Medical Director Mercy EMS Mercy Catholic Medical Center Department of Emergency Medicine 501 South 54th Street Philadelphia, PA 19143 215.748.9740 215.748.9208 (fax)
Maybe I should clarify: Often this triage is done at the EMD level rather than by providers. I hope that most ALS providers would recognize when I patient needs pain medications and should be given parenteral medications. In many EMS systems, only a BLS unit would be dispatched to a fall without major mechanism. For example, only a BLS unit would be dispatched injuries such as a hip fracture after a slip and fall or a child with a wrist fracture after a fall off the jungle gym Derek Isenberg, MD, NREMT-P Medical Director Mercy EMS Mercy Catholic Medical Center Department of Emergency Medicine 501 South 54th Street Philadelphia, PA 19143 215.748.9740 215.748.9208 (fax)
The term "drug seeker" should not even be in a prehospital provider's vocabulary. Our job is not to judge but to treat and relieve pain. Even chronic drug users may have breakthrough pain, drug abusers may have legitimate pain issues, and it is not within either the training nor scope of practice of paramedics to do social evaluations of people complaining of pain in the field. Some while back, we had a similar conversation about the use of ammonia capsules to "awaken" patients who were thought to be malingering. This has no place in EMS either. I have seen medics and doctors revel in recounting how they "punished" a patient they thought was faking. This is abhorrent to medicine. I also know of at least one instance where an EMS service had to pay out $$$ because an ammonia cap was placed under a non-rebreather mask and left on the patient's face. It burned a hole in her skin that had to have skin grafts. Gene Gandy, JD, LP, NREMT-P Derek,
It's been years since I moved a routine hip fractured patient without having analgesia on board. There's no need for it, and to do otherwise is barbaric. Yet, many systems send BLS people who cannot give analgesia, and they move patients and cause them horrific pain. That's just wrong. When will the medical community (read doctors) wake up to the fact that we're not doing adequate pain management in the field, and step up and do something about it? Never, I fear, because there's no money in it. And there's so much cultural crap that leads medical providers to want to punish patients for expressing pain. When systems build in dispatch protocols that ensure that patients with pain management issues will be handled inappropriately, whose fault is that? Well, it all comes back to who actually runs EMS. It ought to be the physicians, but it mostly isn't. It's managers with MBAs and business degrees. Sad. Gene Gandy, JD, LP, NREMT-P I'm wondering what members of this list think about this scenario: Trauma patient who has significant pain and requires cspine precautions/packaging on a long board. The BLS non-transport unit does not immobilize due to the degree of pain and waits for ALS to arrive to administer pain meds prior to immobilization and transfer to the transport vehicle. Alternatively, ALS is on-scene first and opts to treat pain prior to immobilization & transfer to their transport vehicle. This typically involves initiation of an IV and titration of pain meds (narcotics) and potentially delays transports/prolongs scene time by 10-20 minutes. In my experience, ALS scene times are greatly reduced when the trauma patient is packeged prior to their arrival. Presumably, EMS opts to do this selectively on patients who do not appear to have immediatly life-threatening injuries. 1. Is this reasonable patient care? 2. Can BLS personnel reliably identify trauma patients who are unstable or potentially unstable? 3. Can ALS personnel reliably identify trauma patients who are unstable or potentially unstable? 4. What objective data or outcome measure could be used to help identify patients where this practice is undesirable? DTK David T. Kim, M.D., FACEP Idaho Emergency Physicians, P.A. Life Flight Network Boise, ID
How much ketamine are they using? My only experience with ketamine is with ED procedural sedation (4m/kg IM or 1m/kg IV). At these procedural sedation doses, your ability to examine the patient and obtain a history is nil and it may take over an hour for the effects of ketamine to wane. I don't see how ketamine will fit into the prehospital arena, at least at procedural sedation doses. DTK David T. Kim, M.D., FACEP Idaho Emergency Physicians, P.A. Life Flight Network Boise, ID
I’m on the road do not have access to the medical school library to download the papers with the dosage specifications. Below are two of the abstracts.
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Bryan E. Bledsoe, DO, FACEP, FAAEM Clinical Professor of Emergency Medicine University of Nevada School of Medicine Attending Emergency Physician University Medical Center of Southern Nevada Las Vegas, Nevada Pre-hospital use of ketamine for analgesia and procedural sedation. London Helicopter Emergency Medical Service, Department of Pre-hospital Care, The Royal London Hospital, London E1 1BB, UK. Comment in: * Emerg Med J. 2009 Oct;26(10):760-1.
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